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APPLICATION FOR-PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> S 1601 E. HAZEL T ON AVE., STOCKTON, CA , <br /> t Telephone (209) 466-6181 ' <br /> _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complete in Triplicate) <br /> /or install the work <br /> lication is <br /> Application is hereby made <br /> to the <br /> Joaquin County Ordinance No.Districtealth549 for sewage or No. 1862 farewell/pump and the Rules and herein <br /> described. <br /> ations of the San Joaquin <br /> made in compliance wit q I <br /> Local Health District. <br /> City 1r`� Lot Size <br /> 74'51-57 PM i I <br /> • Job Address <br /> Phone <br /> Owner's Name r� Address <br /> , ( ..-. �+ <br /> i t �`� J a s� Odle License No. 3 t •.I- Phone. <br /> Contractor �� Address <br /> NEW WELL —C�WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK _. SEWER LINES DISPOSAL FLD. — PROP. LINE <br /> FOUNDATION AGRICULTURE WELL L OTHER WELL— PITS/SUMPS, <br /> R <br /> INTENDED USE TYPE•OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATiC3 Dia. of Well Casing <br /> fl Industrial ""�'�� Open Bottom El Manteca Dia. of Well Excavation q <br /> Type of Casing y Specifications <br /> 11<DomEl Gravel Pack ❑ Tracy Depth of Grout Seal T iE Type of Grout <br /> p Public ❑ Other ❑ Delta <br /> ❑ Irrigation • ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> :y Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> i Well Destruction ❑ Well Diameter Sealing Material Itop 50'} <br /> Depth t Filler Material [Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALT101Vd El❑ DESTRUCTION <br /> ❑ aNailable�wi h ne200 permitted if public sewer is <br /> Installation will serve: Residence_f Commer Ic al_ Other— <br /> Number <br /> thrNumber of living units: Number ol'bedrooms <br /> 1, Water table depth <br /> Character of soil to a depth of 3 feet: ' <br /> r . ! \. 0 Capacity No. Compartments <br /> SEPTIC TANK '- Type/,Mfg <br /> C Method of Disposal <br /> PKG. TREATMENT PLT. EJ' f^ / L L Property Line <br /> # / Disiance to nearest: Well I Foundation <br /> 5 %YTotallength/size <br /> LEACHING LINE ' .D �•No.,,&'Length of lines Foundation Property Line <br /> FILTER BED ❑F Distance to.nearest: Well y <br /> a f Number <br /> M SEEPAGE PITS/ ❑ Depth Size � t <br /> r 'O Distance to nearest: Well Foundation PropertyCine <br /> SUMPS t <br /> R� <br /> j DISPOSAL PONDS ❑ <br /> I nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that l have prepared this application a <br /> �?rules and regulations of the San Joaquin Local-Health District. <br /> k A <br /> Home owner or licensed agent's signatu a certifies the following: "I certify that in the performance of the work for which this permit is issued, I shallnot <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of California." } N I (- <br /> The applicant t caH for alhre! Ired inspects Complete drawing on reverse side., �P ?J'7 <br /> Title: —f "'`� Date: // <br /> /signed <br /> FOR DEPARTMENT USE ONLY — <br /> �,_.,;. _ Date ` D Area <br /> e' .,=Application Accepted by (�z ; 3 <br /> Pit or Grout Inspection by Date <br /> b 4 Final inspection by Date <br /> r <br /> Additional Comments: ` <br /> C1Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ;T <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk; CA 95201 <br /> k <br /> CK RECEIVED BY DATE EPER;MIT* .FEE AMOUNTDUE AMOUNT REMITTED CASHINFO+'EH13-24(REV. <br />